Marie Lyn Custodio, NURSE PRACTITIONER

Primary specialty

Family Nurse PractitionerTaxonomy code 363LF0000X

License

95013240 Issued in CA

Practice address

3327 Rosecrans St
San Diego, CA 92110-4223

Phone

(619) 225-9691

NPI assigned

Jan 15, 2020

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in CA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Nurse Practitioner

Education

Other, 2019

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Southern California Permanente Medical GroupGroup PAC ID 6002729175, 11,250 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Credentials

Nurse Practitioner

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Southern California Permanente Medical Group

  • Health Maintenance Organization
  • Baldwin Park, CA
  • NPI 1770515280
  Medicare reassignment Care Compare group NPD
• Southern California Permanente Medical Group

  • Health Maintenance Organization
  • San Diego, CA
  • NPI 1023425972
  NPD
• Southern California Permanente Medical Group

  • Health Maintenance Organization
  • Santa Clarita, CA
  • NPI 1316409410
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1579046400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1634774400000",
    "number": "1356981526",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3327 ROSECRANS ST",
            "city": "SAN DIEGO",
            "state": "CA",
            "postal_code": "921104223",
            "telephone_number": "619-225-9691"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3327 ROSECRANS ST",
            "city": "SAN DIEGO",
            "state": "CA",
            "postal_code": "921104223",
            "telephone_number": "619-225-9691"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1419 E 8th St",
            "address_purpose": "LOCATION",
            "city": "National City",
            "state": "CA",
            "postal_code": "919502602",
            "country_code": "US",
            "telephone_number": "619-718-1743",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "2760 Fletcher Pkwy",
            "address_purpose": "LOCATION",
            "city": "El Cajon",
            "state": "CA",
            "postal_code": "920202110",
            "country_code": "US",
            "telephone_number": "619-461-4411 x8221",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "CUSTODIO",
        "first_name": "MARIE LYN",
        "credential": "NURSE PRACTITIONER",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2020-01-15",
        "last_updated": "2021-10-21",
        "certification_date": "2021-10-21",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": "CA",
            "license": "80555",
            "primary": false
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "CA",
            "license": "95013240",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "SOAP",
            "endpointTypeDescription": "SOAP URL",
            "endpoint": "https://careepicwest.kp.org:14430/Interconnect-prodcalgateway/wcf/epic.community.hie/xcpdrespondinggatewaysync.svc/scalceq",
            "affiliation": "Y",
            "endpointDescription": "Carequality",
            "affiliationName": "Southern California Permanente Medical Group",
            "use": "HIE",
            "useDescription": "Health Information Exchange (HIE)",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "C-CDA",
            "address_1": "17284 Slover Ave Ste 205",
            "city": "Fontana",
            "state": "CA",
            "country_code": "US",
            "postal_code": "923377584",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Matthew John Cusolito
• Peter Hodson Custis, MD
• Alvin Fontimayor Custodio
• Christopher Bautista Custodio, RN
• Ebony Andrea Custodio
• Laura Rodgers Cutchall, PT
• Cameron Cuthbert
• Lara May Cuthbert, B.S.
• Leiah Ellen Cutkomp
• Apryl Lynn Cutler, NP

• Family Nurse Practitioner in San Diego, CA
• Providers in San Diego, CA by specialty
• Family Nurse Practitioner in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 21, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.